Immunization

Headline

Following years of gradually increasing coverage, progress towards full immunization of

all two-year-olds has stalled since 2004, standing at 82 percent in 2006. (See Figure 1)

Importance

Diseases that once spread quickly and killed thousands are now largely controlled by
vaccines. Vaccines are given early in life because many vaccine-preventable diseases are
more common and more deadly among infants and small children. Additionally,
childhood immunization is an important step in maintaining high vaccination levels,
which prevent outbreaks of such diseases.1 It is unlikely that an individual who is
immune to a disease will transmit it to someone else. In this way, vaccination protects not
only the child receiving the vaccine, but also those in the child’s community. For this
reason, most schools require that children be fully immunized when enrolling.2 Protecting
children against severe illnesses also results in positive outcomes other than improved
physical health, including the ability to attend school more regularly and the absence of
increased family stress.3

The Centers for Disease Control and Prevention (CDC) recommends vaccinating children
against most vaccine-preventable diseases by the time they are two years old.4 The
CDC’s immunization schedule for children recommends four doses of the diphtheria,
tetanus, and pertussis (DTP) vaccine, three or more doses of polio vaccine, one or more
doses of the measles-mumps-rubella (MMR) vaccine, three or more doses of the
Haemophilus influenzae type b (Hib) vaccine, the hepatitis B vaccine, and the varicella
(chickenpox) vaccine. The DTP, polio, MMR, and Hib vaccines are collectively referred
to as the combination series or 4:3:1:3 vaccine. Since 2002, the CDC has also tracked a
new combination series that includes all of these vaccines (called the 4:3:1:3:3:1 series).
As of 2005, 29 to 34 states (depending on which of these individual vaccines were
examined) achieved a vaccination coverage rate of 95 percent or more among children
entering kindergarten─meeting a Healthy People 2010 objective.5

Trends

The proportion of children ages 19 to 35 months receiving the combined series (4:3:1:3)
vaccines increased from 69 percent to 83 percent between 1994 and 2004. Since this
time, however, progress towards full immunization of all two-year-olds has stalled,
standing at 82 percent in 2006. (See Figure 1)

Vaccination rates for the hepatitis B vaccine, first recommended in the 1990s, increased
rapidly between 1994 and 2006, from 37 percent to 93 percent. Rates for varicella
(chickenpox) vaccines, also first recommended in the 1990s, have climbed steadily from
26 percent in 1997 (the first year for which data are available) to 89 percent in 2006. (See
Table 1)

During the last few years, the proportion of children who received all of the vaccinations
in the combined series plus hepatitis B and varicella (4:3:1:3:3:1) has increased. In 2006,
77 percent of young children ages 19 to 35 months received this combination, an increase
from 66 percent in 2002. (See Table 1)

Differences by Race and Ethnicity

There were no significant differences in childhood vaccination rates by race/ethnicity. In

2006, the percentages of children who received the combined series of vaccines (4:3:1:3),
included 79 percent of non-Hispanic blacks, 82 percent of Hispanics, 80 percent of
Asians, and 84 percent of non-Hispanic whites. Meanwhile, the proportion of these
groups receiving the combined series plus hepatitis B and varicella rates (4:3:1:3:3:1)
ranged between 74 and 78 percent. (See Table 1)

Note: Estimates for specific race groups were revised in 1997 to reflect the new OMB
race definitions, and include only those who are identified with a single race. Hispanics
may be of any race.

Differences by Poverty Status

Children in families with incomes below the poverty level are less likely than are those
with families with incomes at or above the poverty level to receive the combined series
vaccination (4:3:1:3) (78 percent and 84 percent, respectively, in 2006). (See Figure 2)

Differences by Type of Immunization

In 2006, national immunization rates of children ages 19-35 months for MMR, polio,
hepatitis B and Hib vaccines each met or exceeded 90 percent, the Healthy People 2010
target levels. However, only 85 percent had received the DTP vaccine and 89 percent had
received the chickenpox vaccine. (See Figure 3)

State and Local Estimates

2006 data for states are available for the combined series and individual vaccinations
from the National Immunization Survey at:
http://www.cdc.gov/vaccines/stats-surv/imz-coverage.htm#nis

State-level estimates for 2006 are available by race and Hispanic origin from the State
Health Facts web site of the Kaiser Family Foundation at:
http://www.statehealthfacts.kff.org/comparebar.jsp?ind=55&cat=2
International Estimates

2005 International estimates for national and local levels can be found in UNICEF’s
Immunization Survey.
http://www.unicef.org/publications/files/Immunization_Summary_2007.pdf

National Goals

Through its Healthy People 2010 initiative, the Federal government has set a national
goal to increase the percentage of children who have received vaccines. The 2010 goal is
for 90 percent of children aged 19-35 months to be immunized against DTP, polio,
MMR, Hib, hepatitis B, and varicella.

More information is available at:

http://www.health.gov/healthypeople/Document/HTML/Volume1/14Immunization.htm#
_Toc494510242

Definition

Combined Series (4:3:1:3) Vaccine- includes 4 or more doses of diphtheria and tetanus
toxoids and the pertussis vaccine (DTP), 3 or more doses of an oral polio vaccine, 1 or
more doses of a measles-containing vaccine, and 3 or more doses of Haemophilus
influenzae type b vaccine (Hib)

Combined Series (4:3:1:3:3:1) Vaccine- includes 4 or more doses of diphtheria, tetanus,

and pertussis vaccine (DTP), 3 or more doses of polio vaccine, 1 or more doses of a
measles-containing vaccine, 3 or more doses of Haemophilus influenzae type b vaccine
(Hib), three or more doses of hepatitis B vaccine (HepB), and one or more doses of
varicella.

Vaccines and their related diseases:

Tetanus- lockjaw
Pertussis- whooping cough
Haemophilus influenzae type b- Hib Disease
Varicella- chickenpox

For further information about children’s immunizations, including definitions and

recommendations, please visit the CDC’s “Parents Guide to Childhood Immunizations”
at http://www.cdc.gov/vaccines/pubs/parents-guide/default.htm.

The 2007 Recommended Childhood and Adolescent Immunization Schedule, published

by the CDC, is available online at http://www.cdc.gov/nip/recs/child-schedule.htm.
Data Source

Data for 2006: Centers for Disease Control and Prevention, National Immunization
Program (2007). NIS data, tables, Jan-Dec 06. Available online at:
http://www.cdc.gov/vaccines/stats-surv/nis/data/tables_2006.htm

Data for 2005: Centers for Disease Control and Prevention, National Immunization
Program (2006). NIS data, tables, Jan-Dec 05. Available online at:
http://www.cdc.gov/vaccines/stats-surv/imz-coverage.htm#nis

Data for 2004: Centers for Disease Control and Prevention, National Immunization
Program (2005). NIS data, tables, Jan-Dec 04. Available online at:
http://www.cdc.gov/vaccines/stats-surv/imz-coverage.htm#nis

Data for 2003: National Immunization Program (2004). Immunization Coverage in the
U.S.: Results from National Immunization Survey. Centers for Disease Control and
Prevention. Available online at:
http://www.cdc.gov/vaccines/stats-surv/imz-coverage.htm#nis

All data for 2002 and data by race for 2000-2001: National Immunization Program
(2003). Immunization Coverage in the U.S.: Results from National Immunization Survey.
Centers for Disease Control and Prevention. Available online at:
http://www.cdc.gov/vaccines/stats-surv/imz-coverage.htm#nis

All other data for 1995-2001: National Center for Health Statistics. (2003). Health United
States, 2003 With Chartbook on Trends in the Health of Americans. National Center for
Health Statistics. 2003. Table 71
http://www.cdc.gov/nchs/data/hus/hus03.pdf

Data for 1994: Health, United States, 2001, Centers for Disease Control, National Center
for Health Statistics. Table 73 (updated)
http://www.cdc.gov/nchs/data/hus/hus01.pdf

Raw Data Source

National Immunization Survey

http://www.cdc.gov/nis/

Approximate Date of Next Update

2008
1
“Parents Guide to Immunization: Why Immunize?” A publication by the National Immunization Program
of the Center for Disease Control and Prevention. Available at:
http://www.cdc.gov/vaccines/pubs/parents-guide/default.htm
2
Communicating with Parents about Immunization: Common Questions about School Immunization Laws.
(2002). A resource kit from the National Network for Immunization Information. Available at:
http://www.immunizationinfo.org/assets/files/PDFs/KIT_FULL.pdf
3
Halle, T., Zaff, J., Calkins, J., and Margie, N.G. (2000). “Part II: Reviewing the Literature on
Contributing Factors to School Readiness.” Final Report to the Knight foundation: Background for
Community-Level Work on School Readiness: A Review of Definitions, Assessments, and Investment
Strategies. Washington, DC: Child Trends. Available at:
http://www.childtrends.org/Files/LIT__REVIEW__DRAFT__7.pdf
4
“Child and Adolescent Immunization Schedule: Are Your Child’s Vaccinations Up to Date?” (2007). A
publication by the National Immunization Program of the Center for Disease Control and Prevention
Available at: http://www.cdc.gov/vaccines/recs/schedules/child-schedule.htm#printable
5
Stanwyck, C., Davila, J., Lyons, B., Knighton, C. “Vaccination Coverage Among Children Entering
School --- United States, 2005--06 School Year”. MMWR Weekly. CDC: October 20, 2006. Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5541a3.htm
Figure 1
Percentage of Children Ages 19-35 Months Receiving the
Combined Series Vaccination (4:3:1:3), 1994-2006
100

81 83 82 82
74 76 76 79 78 76 77 78
80
69

60
Percent

40

20

0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Source: Data for 1994 from: Eberhardt MS, Ingram DD, Makuc DM, et al. Health, United States, 2001, with Urban and Rural Healthbook.Hyattsville, Maryland: National Center for
Health Statistics. 2001: Table 73. Data for 1995-2001 from: National Center for Health Statistics. (2003). Health United States, 2003 With Chartbook on Trends in the Health of
American. National Center for Health Statistics.Table 71. Data for 2002 from: National Immunization Program (2003). Immunization Coverage in the U.S. Results from National
Immunization Survey. Centers for Disease Control and Prevention. Data for 2003: National Immunization Program (2004). Immunization Coverage
in the U.S.:Results from National Immunization Survey. Centers for Disease Control and Prevention. Available online at:
http://www.cdc.gov/nip/coverage/default.htm#. Data for 2004: Centers for Disease Control and Prevention, National Immunization Program
(2005). NIS data tables,Jan-Dec 04 . Available online at: http://www.cdc.gov/nip/coverage/default.htm#. Data for 2005: Centers for
Disease Control and Prevention, National Immunization Program (2006). NIS data, tables, Jan-Dec 05.
http://www.cdc.gov/nip/coverage/NIS/05/toc-05.htm. Data for 2006: Centers for Disease Control and Prevention, National Immunization
Program (2007). NIS data, tables, Jan-Dec 06. http://www.cdc.gov/vaccines/stats-surv/nis/data/tables_2006.htm
Figure 2
Percentage of Children Ages 19-35 Months Reciving the 4:3:1:3
Vaccination, by Poverty Level, 2006

100

83 85 84 84
82 81
77 79 79 78 79 79
80
72
78 79 78
73 71 72 72 76
71 74
60 69
67 Below
Percent

Poverty
61

At or Above
40 Poverty

20

0
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Source: Data for 2006: Centers for Disease Control and Prevention, National Immunization
Program (2007). NIS data, tables, Jan-Dec 06. http://www.cdc.gov/vaccines/stats-
Figure 3
Percentage of Children Ages 19-35 Months
Receiving Individual Vaccinations in 2006
100
93 92 93 93
89
82 85

80

60
Percent

40

20

0
Combined DTP/DT/DTaP Polio MMR Hib Hepatitis B Varicella
Series (4:3:1:3) (Chickenpox)

Source: Data for 2006: Centers for Disease Control and Prevention, National Immunization Program (2007). NIS data, tables,
Jan-Dec 06. http://www.cdc.gov/vaccines/stats-surv/nis/data/tables_2006.htm
Table 1
Vaccinations of Children 19-35 Months of Age: United States, 1994-2006 (Percentage)
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Combined series (4:3:1:3)1
Race and Hispanic Origin
All Races 69 74 76 76 79 78 76 77 78 81 83 82 82
White, non-Hispanic 72 76 79 79 82 81 - - - - -
White only, non-Hispanic 2 - - - - - - 80 79 80 84 85 84 84
Black, non-Hispanic 67 70 74 73 73 74 - - - - -
2
Black only, non-Hispanic - - - - - - 70 71 71 75 76 81 79
Hispanic 62 68 71 73 75 75 73 77 76 79 81 81 82
Asian or Pacific Islander, non-Hispanic 60 76 78 71 79 77 - - - - -
2
Asian only, non-Hispanic - - - - - - 75 76 83 81 84 82 80
American Indian or Alaska Native, non-Hispanic 82 69 82 73 78 75 - - - - -
2
American Indian or Alaska Native only, non-Hispanic - - - - - - 72 75 NA 77 75 NA 80
Poverty Status
Below Poverty 61 67 69 71 74 73 71 72 72 76 78 79 78
At or Above Poverty 72 77 79 79 82 81 78 79 79 83 85 84 84
Location of Residence
Central City 68 72 74 74 77 77 73 75 75 80 81 81 82
Remaining Areas inside Metropolitan Statistical Area 70 75 78 78 81 79 78 78 80 82 84 84 83
Outside Metropolitan Statistical Area 70 75 77 77 81 80 79 79 77 81 82 81 83
Individual Vaccines
3
DTP/DT/DTaP (4 doses or more) 76 78 81 82 84 83 82 82 82 85 86 86 85
Polio (3 doses or more) 83 88 91 91 91 90 90 89 90 92 92 92 93
Measles-Mumps-Rubella 89 90 91 90 92 92 91 91 92 93 93 92 92
4
Hib (3 doses or more) 86 91 91 93 93 94 93 93 93 94 94 94 93
Hepatitis B 37 68 82 84 87 88 90 89 90 92 92 93 93
Varicella (Chickenpox)5 - - - 26 43 58 68 76 81 85 88 88 89
Combined series (4:3:1:3:3:1)6
Race and Hispanic Origin
All Races - - - - - - - - 66 73 76 76 77
White only, non-Hispanic 2 - - - - - - - - 66 74 77 76 78
Black only, non-Hispanic2 - - - - - - - - 62 68 71 76 74
Hispanic - - - - - - - - 66 71 76 76 77
Asian or Pacific Islander, non-Hispanic - - - - - - - - - - -
Asian only, non-Hispanic2 - - - - - - - - 74 76 80 77 76

American Indian or Alaska Native only , non-Hispanic2 - - - - - - - - NA 69 67 NA 74

Poverty Status
Below Poverty - - - - - - - - 62 70 73 74 74
At or Above Poverty - - - - - - - - 66 74 77 77 78
Location of Residence
Central City - - - - - - - - 64 72 75 75 77
Remaining Areas inside Metropolitan Statistical Area - - - - - - - - 68 74 78 78 78
Outside Metropolitan Statistical Area - - - - - - - - 61 70 74 74 75
"-" Indicates no data available; NA (Not Available) indicates that the sample size for this group was too small to produce reliable estimates.
1
The 4:3:1:3 combined series measures the number of children who have received 4 key immunizations: 4 or more doses of diphtheria, tetanus, and pertussis vaccine, 3 or more doses of polio
vaccine, 1 or more doses of a measles-containing vaccine, and 3 or more doses of Haemophilus influenzae type b vaccine (Hib)
2
Persons of Hispanic origin may be of any race. These estimates for the years 2000-2004 have been revised to reflect the new OMB race definitions and only include those who are identified with a single race.
3
Diphtheria and tetanus toxoids and pertussis vaccine, diphtheria and tetanus toxoids, and diptheria and tetanus toxoids and acellular pertussis vaccine
4
Haemophilus influenzae type b vaccine (Hib)
5
Data collection for Varicella began in July 1996
6
The 4:3:1:3::3:1 combined series measures the number of children who have received 6 key immunizations: 4 or more doses of diphtheria, tetanus, and pertussis vaccine (DTP), 3 or more doses of polio vaccine, 1 or more doses of a measles-
containing vaccine, 3 or more doses of Haemophilus influenzae type b vaccine (Hib), three or more doses of hepatitis B vaccine (HepB), and one or more doses of varicella.
Notes: Final estimates of data from the National Immunization Survey include an adjustment for children with missing immunization provider data. Poverty status is based on family income and family size using Bureau of the Census poverty
thresholds. Children missing information about poverty status were omitted from analysis by poverty level. In 2000, 14.2 percent of all children, 17.9 percent of Hispanic, 12.1 percent of non-Hispanic white, and 16.1 percent of non-Hispanic
black children were missing information about poverty status and were omitted.
Sources: Data for 1994 from: Eberhardt MS, Ingram DD, Makuc DM, et al. Health, United States, 2001, with Urban and Rural Healthbook. Hyattsville, Maryland: National Center for Health
Statistics. 2001: Table 73. Data for 1995-2001 from: National Center for Health Statistics. (2003) Health United States, 2003 With Chartbook on Trends in the Health of Americans. National
Center for Health Statistics. 2003. Table 71. Data for 2002 and 2003 and race estimates for 2000 and 2001 from: National Immunization Program (2003). Immunization Coverage in the U.S.
Results from National Immunization Survey. Centers for Disease Control and Prevention. http://www.cdc.gov/vaccines/stats-surv/imz-coverage.htm#nis. Data for 2003: National
Immunization Program (2004). Immunization Coverage in the U.S.: Results from National Immunization Survey. Centers for Disease Control and Prevention.
http://www.cdc.gov/vaccines/stats-surv/imz-coverage.htm#nis. Data for 2004: Centers for Disease Control and Prevention, National Immunization Program (2005). NIS data, tables, Jan-Dec
04. http://www.cdc.gov/vaccines/stats-surv/imz-coverage.htm#nis. Data for 2005: Centers for Disease Control and Prevention, National Immunization Program (2006). NIS data, tables, Jan-
Dec 05. http://www.cdc.gov/vaccines/stats-surv/imz-coverage.htm#nis Data for 2006: Centers for Disease Control and Prevention, National Immunization Program (2007). NIS data, tables,
Jan-Dec 06. http://www.cdc.gov/vaccines/stats-surv/nis/data/tables_2006.htm